Community Spot Application

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Thank you for your interest in our community spot. Please complete the application to the best of your ability.

Guidelines & Notes:

You will receive the same quality of care and the same commitment we bring to every client.

Clients are eligible for up to 8 sessions, which will be scheduled immediately following a consultation session to determine best fit.

Free sessions are only valid towards 30-minute individual therapy sessions.

We ask that you commit to the process.

We ask thar you respect our 24-hour cancellation policy so we can serve you fully.

A cancellation or no-show fee of $50 will be applied if a session is missed.

This is only available to residents of Ontario, Canada at this time.

Please note: This program is subject to availability and not applicable for clients with insurance coverage. If you require assistance, please do not hesitate to contact us at admin@cognicaretherapy.ca
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Name
First Name
Last Name
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Email
example@example.com
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Phone Number
Please enter a valid phone number.
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What are some goals that you'd like to target in 8 sessions?
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Please share a little about your current circumstances and how this spot would benefit you. (You don’t need to prove anything, just share what feels comfortable. This helps us understand if this offering is the right fit.)
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Do you currently have extended health benefits under your insurance for coverage of speech therapy or speech language pathology, etc that is valid in Ontario?
Yes
No
I don't know
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What is your current employment status?
Full time
Part time
Student
Unemployed
Self-employed
Hoping to return to work
Restricted from returning to work
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How did you hear about us?
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If you have difficulties typing or providing a written response, please dictate your answers here.
Should be Empty: